Except for the dreadful Ockhi cyclone of 2017, Thiruvananthapuram has been relatively lucky in evading disasters in recent years. Nipah, a virus that killed 17 people, stayed in the northern districts in 2018 and touched Ernakulam the year after that. Floods of 2018 and 2019 mostly left the capital alone when it caused unimaginable levels of damage in the central and northern parts of Kerala.
The COVID-19 outbreak, too, appeared to be in negligible numbers the first few months, but all that changed in a few days in July 2020. On July 1, the number of active cases in Thiruvananthapuram was 78. On Friday, July 24, the number was 2,650.
More worrisome is the number of people who got it through contact. Of the 3,094 cases reported till July 24 in Thiruvananthapuram, 2,719 were through local transmission and the rest were imported cases (people who came to the state from other places). In all the other districts, except Ernakulam, COVID-19 cases have been mostly imported, with fewer numbers of local transmissions. It is, as the doctors say, more worrisome when local transmissions become more in number, leading inevitably to community spread, as it did in two areas of Thiruvananthapuram last Friday. Chief Minister Pinarayi Vijayan confirmed the fears of the people who had been asking questions of community spread since May. Poonthura and Pulluvila of Thiruvananthapuram had community spread, he said.
There have also been 11 deaths of COVID-19 patients in Thiruvananthapuram till July 24.
The first three cases of COVID-19 in Thiruvananthapuram were reported on March 13, 2020, four days after the second wave of the disease began in Kerala.
For two months after that, the active cases in the district remained below 10. Till the first week of July, the most number of cases reported on a single day was 14. But the relaxed state of affairs would soon change.
The first signs of a possible spike in cases came on July 3, 4 and 5, when 17, 16 and 27 new cases were respectively reported.
On July 3, three unusual cases came — of a migrant labourer working in a shopping complex in Palayam, a lottery agent in Vanchiyoor and a fish-seller in Poonthura. All of them would have come in contact with a number of people while doing their jobs.
Disinfection in Palayam market
It was on July 5 that a triple lockdown was declared in the capital when it was found that 22 people contracted the disease via contact.
For a week since then, the roads of the capital had once again become empty, wearing the look they did in the last week of March and the 14 days in April when the whole country went into lockdown.
Father Bebinson, who was the parish priest of Poonthura, remembers one of the first men to have got COVID-19 in the coastal area. “One person had gone off the coast to bring fish from elsewhere (reportedly from Kanyakumari), he later came to the Kumarichantha market in Poonthura with the fish. He later tested positive. By then, he had sold his fish to several women who would then sell it in different parts of the city. Some of these women had contracted the disease from him and then inadvertently passed it on to their families that included small children,” says Fr Bebinson.
On July 7, the CM's office released the news that a person who tested positive in Poonthura had 120 primary contacts. That day, there were 54 positive cases in Thiruvananthapuram, and 26 of them were in Poonthura. By then, 119 of the 600 samples tested from the region had come back positive – which meant that one in five people tested positive.
“The spread was inevitable. These areas are congested, with people sometimes sharing a wall between the houses," Fr Bebinson says.
Poonthura is a thickly populated area and there is a population density of more than 5,000 per sq km. It was necessary to control habitual gatherings of people and implement physical distancing. But the sudden announcement of a triple lockdown didn’t give people the time to prepare for it, says T Peter, General Secretary of National Fishermen Forum.
“It was too sudden and the government should have done it more systematically. People could not even gather basic food supplies. There was no time to even buy milk for little children. The police deployed in the area did not allow the people to go out and buy anything,” Peter says.
On July 8, the police said that 25 commandos under SAP (Special Armed Police) Commandant-in-Charge L Solomon have been deployed on special duty in Poonthura. Instructions were given to Coast Guard, Coastal Security and Marine Enforcement to prevent boats from leaving or coming to Poonthura.
A day later, CM Pinarayi said that Poonthura was witnessing a super-spread — which is when the infection spreads from one person to many others. He said that it was only a step away from the dreaded community spread.
As such they were already suffering with the fishing ban, says Peter. “There is no money coming. Earlier when we had these trawling bans, the people would depend on the money that relations in Gulf countries could send them. But now with the COVID-19 pandemic, most of the Gulf expatriates in these areas have come back. The government’s package of offering a family five kilos of rice is not enough. There are families of eight or ten members living there. They should provide free grocery kits at least for a month.”
There should also be a cash package, says Advocate Charles George, President Matsya Thozhilali Aikyavedi.
Initially, the government handled the situation well, he says. After the country-wide lockdown in March, fishing was allowed in small boats since people depended on it for their livelihood. “Step by step, they allowed bigger boats too. There was also strict distancing imposed in markets and the process of auctioning was stopped to avoid gatherings at landing centres and harbours. But later on there was not enough surveillance,” he says.
When there is such a high population density in places like Poonthura, strict caution should have been observed from the beginning, Charles says. “Fishing is not a one man job - there is catching, collecting and distribution of the fish. Many people go together, sometimes 50 men in a boat. So there should have been stricter vigilance much early on. And later on they should have allowed regulated fishing, in place of complete ban since so many families depend on it for their livelihood.”
Peter notes that primary health centres in these areas should also function for 24 hours. Now the doctors leave by afternoon, he says. “Also, importantly, certain media’s propaganda in creating unnecessary fear should stop. Recently it spread through social media that 17,000 people in Pulluvila have COVID-19. When the media reports these numbers without factual validation, it creates a lot of fear among the people. These people were called heroes during the floods when the fishermen fearlessly took out their boats to save stranded people elsewhere. Now is the time to show them some justice,” Peter adds.
Meanwhile, cases began to rise every day in the district, increasing from 54 new ones reported on July 7 to 129 fresh cases on July 10. The day it crossed 100 cases also turned out to be a bad one for health workers, who undertook the risk of going to Poonthura to collect samples for tests. A commotion broke out and scores of people were on the road, protesting. They didn’t want the tests, the tests were a lie, they said. They crowded around the car of health workers, that a female doctor, her nursing staff and lab assistant were travelling in. Someone opened a window and coughed, another spat on the car.
It was apparently a misunderstanding spread by fake messages that the antigen test done on them were inaccurate and they were needlessly sent to hospitals.
But there was also another reason for the protest. The sudden lockdown did not give time for the townsfolk to prepare. The shops in the area were not allowed to open even during the 7 am to 11 am window in the morning like the rest of the city corporation -- also under lockdown. When the people walked to the nearest village, the shopkeepers refused to sell them anything for fear of contracting COVID-19.
Morning protest in Poonthura, Thiruvananthapuram, which is a hotspot and reported the first super spread of Covid 19 in the state. People protested against the restrictions that's made life difficult for them.— Cris (@cristweets) July 10, 2020
Minister Shailaja promised to address issues. pic.twitter.com/O7O88AO17K
Corrective action was put in place. District administration officials, who were unaware of the situation, came to the place to make peace. Shops were allowed to open like in the rest of the city. And to correct the misunderstanding, local leaders and priests like Fr Bebinson that people listened to were brought to talk to them. Two days later, the same people welcomed back the health workers with bouquets and flowers.
This meant that for two days there was no testing in one of the highly risky areas of the city. Dr Dyuthi Haridas, a government doctor who was in the car that day, and had gone into quarantine afterwards, says, “Though our measures were exemplary and very strict in the initial stages of management, the compliance to it dropped significantly as the number of cases shot up.”
When people had no symptoms, they refused to believe they had the disease. “I think this could also be due to the fact that death rates have dropped from 20% to 7% and most people who harbour the disease remain asymptomatic or mildly symptomatic and hence, the fear of disease as such has come down among the people. This is my personal opinion,” Dr Dyuti says.
Dr Amar Fettle, state nodal officer for COVID-19, made a similar observation. People assume that those infected with the virus would show symptoms. But a good percentage of people show no symptoms at all.
It is also the opinion of volunteer Suresh, who works in Poonthura as a member of the Sannadha Sena. “The picture they had of the disease from watching television news was a different one. That it was a dreaded disease and killed people. But when it came to them, many didn’t even have symptoms or else it came as a small cold and fever. They could not accept it. Even though they wear masks they don't care about physical distancing,” says Suresh.
Dr Dyuti joined back duty a few days ago. She asks poignantly, “Have you seen how their houses are stacked near one another with no walls in between?”
The same point that Fr Bebinson made, they are too closely knit. When videos of the July 10 street protest came online, you could see people standing close by or outside their little houses. For many of them, home is a small space that extends to the street outside, Fr Bebinson earlier told TNM.
“It may not be just the one person from Kanyakumari. There may still be many asymptomatic carriers among us who are spreading the disease unknowingly. An asymptomatic person will not take strict precautions as he/she will not even know they have the disease. But that one person is enough for a cluster spread,” Dr Dyuti says.
And indeed, the number of new cases in Thiruvananthapuram crossed 200 on July 14 and 300 on July 16. By July 20, there were more than 2,000 active cases in the capital.
“You cannot compare Thiruvananthapuram or for that matter even Kerala with other parts of the country. We have a high population density, it is easier for a disease to spread fast. What happened in the coastal area can happen to any thickly-populated area. Lack of awareness can be a contributing factor, so is the implementation of the protocol. Problem is how some people began underestimating the disease. Many of us are still doing it,” says Dr Sulphi Noohu, of Indian Medical Association (IMA) Kerala chapter.
The IMA had recommended institutional quarantine for all those who came from abroad but it was not practical, Dr Sulphi says.
“More than two lakh people have come from abroad and it won’t be possible to put them all in institutional quarantine. The problem is many people violate the quarantine, and it becomes easier when it is at home. This had always happened from the earlier days of the disease. But back then the positive cases were fewer in number so the impact was not so bad.”
The same callousness came at a price for 78 employees of the Ramachandran shopping complex who tested positive in mid-July. Two days later when the number further rose, Ramachandran and another busy shopping centre, Pothys, lost their license for violating quarantine and physical distancing norms, necessary to keep COVID-19 in check.
Among those who are not careful enough in following the precautions are also councillors of the city corporation, seven of whom have tested positive in recent days. Mayor K Sreekumar has gone into quarantine.
Perhaps more attention should be given to such crowded areas as markets, experts say. After the Kumarichantha market of Poonthura, the Chalai market in the city – another busy area – too, has witnessed 11 positive cases in recent days.
District Collector Navjot Khosa wrote on Wednesday, “Since Monday morning, we have increased random antigen-based testing in Chalai and Karimadom (nearby area) to identify if there is any cluster formation. We will be testing aggressively for the next few days to assess the situation. At the moment, there is no need to panic but to be alert. Please follow all COVID-19 protocol whenever going out of the house for essential activity.”
The question about Kerala doing enough tests has been asked for a while. Executive Director of Kerala Social Security Mission Dr Mohammed Asheel had in an earlier interview to TNM spoken about the test positivity rate or TPR (the number of persons testing positive every 100 cases) being a desirably low number for Kerala (less than 2 on June 1). He also said the number of tests per million should at least be 50 times more than the cases per million – which would prove test adequacy. In the beginning of June, it was still above 60.
But it has fallen below 50 in the recent days. On July 13, CM Pinarayi said that it is 44, which showed that the state had to do more tests. The TPR that day was 2.27%.
The testing numbers of Thiruvananthapuram rose in the last half of June and furthermore in July. On July 4, when the spike began, 516 samples were sent for testing. On July 22, 1,032 samples were sent for testing.
“There should have been more testing in Thiruvananthapuram earlier. The reason that Palakkad stayed on top of the chart with the most number of cases for a long time was because of the number of tests it did,” says Dr Arun NM, an Internal Medicine Specialist in Palakkad.
The fact that Thiruvananthapuram, like Palakkad, is a border district, would also put it at risk, Dr Arun says.
It is also a cause of concern that at least three deaths in Thiruvananthapuram were of patients whose source of the disease has not been traced, Dr Arun says.
The first death in Thiruvananthapuram was on March 31, of a 68-year-old person who got the disease through contact. Five senior citizens whose source of infection had not been traced died after that, three of whom had comorbidities.
“India as a whole is not testing enough,” says Dr Sulphi. “The IMA has been recommending that at least 50,000 per million people be tested. All health workers and doctors must be tested because we see an increasing number of them being infected every day. If this continues, hospitals employing the health workers will be forced to shut down and then who will treat the people?”